Failure to Prevent and Address Resident Sexual Abuse and Neglect
Penalty
Summary
The facility failed to develop and implement effective written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of a male resident with a history of sexually inappropriate behaviors. This resident, who had diagnoses including dementia, metabolic encephalopathy, COPD, diabetes, chronic respiratory failure, end-stage renal failure, and hypertension, was admitted without a care plan addressing his known sexually inappropriate behaviors. Despite documentation from a previous facility recommending placement in a male-only locked unit due to sexual aggression, the facility did not initially identify or address these behaviors upon admission. The resident engaged in sexually inappropriate conduct, including inappropriately touching a student visitor during an activity, making female residents uncomfortable with sexual gestures, and repeatedly being sexually inappropriate with staff. Multiple residents and staff reported feeling uncomfortable or unsafe due to the resident's actions, and these concerns were communicated to facility leadership. However, the facility did not implement effective interventions or services to address the resident's behaviors, nor did they in-service staff on how to properly handle such behaviors to prevent further incidents. The facility's leadership, including the DON and Administrator, failed to recognize or act upon the resident's history and ongoing behaviors. They did not conduct a full investigation or report the incident involving the student to the state agency or law enforcement, as required by policy. Additionally, the facility's abuse prevention policy was not fully implemented, and staff were not adequately trained or informed about handling sexually inappropriate behaviors beyond routine or initial training. These failures resulted in an Immediate Jeopardy situation, as residents and visitors were placed at increased risk for abuse and neglect.
Removal Plan
- The DON, Social Services Director, and designee(s) interviewed/assessed all residents for potential abuse by conducting safe surveys on each resident.
- Resident evaluated by primary care provider and provided a medication update.
- Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted. Psyche consult provided.
- Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible.
- IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions.
- Care plan revisions and interventions communicated to front line staff caring for resident.
- Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident.
- Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes.
- Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies.
- Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting.
- Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect.
- DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Process will be ongoing.
- In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Process will be ongoing.
- The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect. In-service will be ongoing.
- QAPI meeting will be held monthly, and findings discussed.
- The DON will monitor the effectiveness of interventions will be ongoing.
- A pre/posttest on abuse and neglect will be ongoing.
- The facility is still looking for proper placement of resident.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.